Our rating of services improved. We rated them as good because:

• We rated effective, caring, responsive and well led as good and we rated safe as requires improvement.
• We rated three of the hospital’s five services as good and two as requires improvement.
• The rating of surgery stayed the same as our last inspection and the rating of medical care improved.
• We saw improvements in the processes to identify patients who were deteriorating. Staff completed records correctly and we saw evidence of appropriate escalation.
• The trust provided care based on evidence based practice and national guidance. Services reviewed the effectiveness of care through national and local reviews and implemented any findings. We saw improvements in how the trust reviewed effectiveness of the care, through monitoring and auditing compliance with nine fundamental standards.
• Staff cared for patients with care and compassion and respected patient’s wishes. Staff provided individualised care and involved patients and those close to them in decisions about their care and treatment. Staff provided patients with emotional support to minimise their distress.
• Patient’s individual needs were met. Systems were in place for identifying patients living with dementia and learning difficulties and to support them through their hospital stay.
• Staff morale was good and teams worked well together and supported each other. Managers were proud of their staff and success was celebrated through local and trust wide events.

However:

• At this inspection it was apparent the five steps to safer surgery checklist was still not embedded as a routine part of the surgical pathway. The trust had reported three never events associated with wrong site surgery or the wrong prosthesis being inserted. We could therefore not be assured that the checklist was being used correctly consistently.
• The trust did not always meet referral to treatment indicators. We saw high numbers of patients waiting for first and follow up appointments across several outpatient areas. In addition to this the trust declared a serious incident related to a trust wide tracking issue within the electronic database. This resulted in a number of patients being lost to follow up.
• Patients’ records were not always stored securely or in an organised manner. There was a risk that staff may not have access to the information they needed to deliver patient care and that the public could access patients’ confidential records.
• Records we reviewed showed that surgical in-patients were being fasted for too long prior to surgery. Eight out of eight records we reviewed all showed that patients had fasted for longer than national guidance.
• The trust did not always have appropriate numbers of staff to ensure patients received safe care and treatment. The trust had introduced some additional staff and roles to provide cover and mitigate some of the risk. However, despite the shortage of registered nurses in particular, the trust managed staffing well and had a robust escalation and review process.

We spoke with people at the hospital's outpatient reception area. People were complimentary about most aspects of their care, although the waiting time from the appointment on their letter to the actual time seen in a clinic or receiving treatment was an issue with two people. Once person told us that when they attended for their operation, they had to wait four hours for a bed and although staff appeared sympathetic, the person told us that speaking to others, four hours was "lucky" and this person had been sat with another person who had their operation cancelled twice through what were related to them as "winter pressures." Everybody we spoke with felt the staff were trying to help. One person told us that "nurses are pushed off their feet but they get to you and always manage in the end." Another person observed that "if they got their appointment times sorted more accurately, people would feel more comfortable, staff would have to apologise less and be able to get on with their jobs more."

We saw that the areas inspected were clean and tidy with evidence of infection control measures in place. Completion of record keeping was timely and assessments led to planned care. Coping with winter pressures did put one ward inspected under strain which led to some care being not as optimal as the trust had planned.

We spoke with patients on three wards, both regarding their specific care and their general impression of the hospital. Most were satisfied with their care, felt they had been informed over their condition and the course of treatment, felt the wards were clean and tidy and gave positive comments regarding the attention staff were giving them. Some were complimentary about the food whilst anothers felt the quality could be improved.

Comments included “Everybody’s been great,” “friendly and outgoing staff,” “It is nice to be able to walk to theatre rather than be on a trolley, it helps reduce my anxiety.” Can’t really complain.” “All staff happy and really polite.”

The people we spoke to were happy with the level of care and support they had been offered at the birthing centre. They told us that they were impressed with the calm atmosphere and that they trusted the staff and felt safe. They talked to us about the support they had received prior to attending the centre and how they could regularly see their community midwife. People felt that they had been given choices about the care that they wanted and were supported to raise concerns. They spoke highly of the staff and told us that their husband or birthing partner were fully involved.

One person was disappointed that they had been sent home early due to staff shortages.

Hull and East Yorkshire Hospitals NHS Trust operates from two main hospital sites – Hull Royal Infirmary (HRI) and Castle Hill Hospital (CHH) in Cottingham. Castle Hill Hospital has cardiac and elective surgical facilities, medical research teaching and day surgery facilities (the Daisy Building), an ear, nose and throat (ENT), a breast surgery facility and outpatients as well as the Queen’s Centre for Oncology and Haematology. In total, the trust has approximately 1,300 beds and 7,400 staff. The CHH site has over 600 beds. The trust provides services for a population of approximately 602,700 people. This is made up of approximately 260,500 people in the city of Kingston Upon Hull and 342,200 in the East Riding of Yorkshire.

We completed a comprehensive inspection of the trust from the 28 June to the 1 July 2016 which included a review of progress made on the previous inspections in May 2015 and February 2014. We inspected the five core services delivered from CHH which were medicine, surgery, critical care, end of life care and outpatients and diagnostics. In addition, we carried out unannounced inspections on 9 June and the 11 July 2016.

We rated CHH overall as ‘Requires improvement’; the safe, effective, responsive and well led domains were rated as ‘Requires improvement’ with caring rated as ‘Good. There had been improvements made for referral to treatment times (RTT); whilst the trust was not achieving the national standard it was meeting the local trajectories agreed with commissioners and NHS Improvement. Surgery services had improved. End of life care remained ‘Good’ across all domains. However, there was deterioration in the ratings overall for critical care from ‘Good’ to ‘Requires improvement’. Outpatients and diagnostics had improved in some areas and deteriorated in others which changed the rating from ‘Good’ in 2015 to ‘Requires improvement’ overall.

Our key findings were as follows:

• The trust reported and investigated incidents appropriately and the previous backlog had reduced. However, staff in some areas could not tell us about lessons learned or changes to practice.
• The trust had effectively responded to a serious incident reported by Radiology in December 2015 related to a failure to print 50,000 radiology reports. A further seven serious incidents regarding specific patients had been reported, of which four related to this printing issue. These incidents had been identified by the trust, action had been taken to change the system and additional safety alerts had been added which if breached were reported to the medical director.
• A backlog of 30,000 patient episodes/appointments had been identified by the trust prior to the inspection. There had been eight serious incidents declared in outpatients, relating to patients that had not had their appointments when they should. This had led to delays in diagnosis and incidents of varying harm to patients. The trust had put in a clinical validation procedure in June 2016 to reduce the likelihood of this happening again.
• Staff were not always assessing and responding appropriately to patient risk. The trust used a National Early Warning Score (NEWS) to identify deterioration in a patient’s condition. We saw some examples of when escalation of a deteriorating patient had not happened in a timely way and some staff were unclear about what to do if a patient’s score increased (indicating deterioration). The trust was aware of this and was putting actions in place to improve this.
• Falls risk assessments were often not completed or not fully completed. Nutritional assessments were partly completed in the patient records, which may have resulted in a failure to identify patients at risk of malnutrition. We also found poor compliance with the completion of fluid balance charts.
• Nurse staffing shortages were evident across the majority of medical and surgical wards and Board reports indicated that safer staffing levels were not always met. The trust recognised this was an issue and had put in place twice daily safety briefings and associated actions to minimise risk to patients as well as new ward support roles, such as discharge facilitators.
• There were also some gaps within the medical staffing, especially within critical care.

• The Summary Hospital-level Mortality Indicator (SHMI) for the Trust had deteriorated and was 112.2 which was higher than the England average (100) in March 2016. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated there. The Hospital Standardised Mortality Ratio (HSMR) was 98.6 in May 2016 which was similar to the England ratio (100) of observed deaths and expected deaths.
• There were three active outlier mortality alerts at the time of the inspection. These were for septicaemia (except in labour), coronary artery bypass graft (CABG) and reduction of fracture of bone (upper and lower limb). This meant that deaths within these areas had been outside of the expected range. The trust had undertaken a case note review to determine if any of the deaths were avoidable, what lessons could be learnt and actions were then put in place.
• Although medicines were stored and administered appropriately, we found gaps and errors in the recording of medicines administration and in the monitoring of checks of controlled drugs which had been a concern at our 2015 inspection.
• Leadership had improved. There was a clear vision and strategy for the trust with an operational plan on how this would be delivered. We found an improved staff culture, staff were engaged and there was good teamwork.
• Feedback from patients and relatives was positive. We saw good interactions between staff and patients. Staff maintained patients’ privacy and dignity when providing care. Caring within medicine had improved.
• Patients told us they were offered a choice of food and regularly offered drinks. Patients were offered alternatives on the food menu and were provided with snacks, if required, during the day.
• The areas we visited were clean and ward cleanliness scores were displayed in public areas. We observed good infection prevention and control practice on all wards we visited.

We saw several areas of outstanding practice including:

• The urology service had introduced robotic surgery for prostate cancers in May 2015; this had since been extended to cover colorectal surgery.
• The critical care teacher trainers had been shortlisted for a national nursing award for their training courses and had been asked to write an article for a national nursing journal.
• The responsiveness of the Specialist Palliative Care Team (SPCT) in relation to acting on referrals. For example, we saw that the SPCT was prepared to see patients without having received a referral and 98% of patients referred to the team were seen within one working day.
• The bereavement team initiative of providing cards for relatives to write messages to their loved ones.
• The breast care unit were using digital tomosynthesis. This method of imaging the breast in three-dimensions improves the sensitivity of detection of breast cancers by 40% and is more accurate.
• The breast care unit carried out vacuum assisted biopsies. This one-stage procedure avoided patients needing two or three biopsies, significantly reducing the stress and anxiety for the patient and saving on resources.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

• Planning and delivery of care meets the national standards for the referral-to-treatment time indicators and eliminates any backlog of patients waiting for follow ups with particular regard to longest waits.
• Learning from Never events is further disseminated and lessons learnt are embedded.
• Staff are knowledgeable about when to escalate a deteriorating patient using the trust’s National Early Warning Score (NEWS) escalation procedures; that patients requiring escalation receive timely and appropriate treatment and; that the escalation procedures are audited for effectiveness.
• Staff have the skills, competence and experience to provide safe care and treatment especially for patients requiring critical care services.
• Staff follow the established procedures for checking resuscitation equipment in accordance with trust policy.
• Staff record medicine refrigerator temperatures daily and respond appropriately when these fall outside of the recommended range.
• Staff sign drug charts after the medication has been dispensed and not before (or before and after if required) to provide assurance that medications have been given to/ taken by the patient.
• Patients’ food and fluid charts are fully completed and audited to ensure appropriate actions are taken for patients.
• Effective use and auditing of best practice guidance such as the ‘Five steps to safer surgery’ checklist within theatres and standardising of procedures across specialties relating to swab counts.
• Ensure that elective orthopaedic patients are regularly assessed and monitored by senior medical staff.
• Review the critical care risk register to ensure that all risks to the service are included and timely action is taken in relation to the controls in place and escalation to the board.
• Outpatients services have timely and effective governance processes in place to ensure they identify and actively manage risks and audit processes to monitor and improve the quality of the service provided.
• Medical records are stored securely and are accessible for authorised people in order to deliver safe care and treatment, especially within outpatient services.
• There are at all times sufficient numbers of suitability skilled, qualified and experienced staff (including junior doctors) in line with best practice and national guidance taking into account patients’ dependency levels on surgical and medical wards. And specifically to ensure critical care services have sufficient numbers of staff to sustain the requirements of national guidelines (Guidelines for the Provision of Intensive Care Services 2015 and Operational Standards and Competencies for Critical Care Outreach Services 2012).

In addition there were areas where the trust should take action and these are reported at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals